Patient Intake Form

At Performance Rehab Inc, we want to maximize your time with us. Prior to your first visit, please fill out the new patient intake form below and submit it. Also bring along proof of ID along with your insurance information.

Privacy Statement

Please note that no personal information from this form will be stored on our website database. All information is securely directed and saved in our clinic’s Electronic Medical Record (EMR) system where all data is encrypted. The patient information will only be used by the clinic and will not be passed on to any third party.

Click here for Notice Of Privacy Practices